Dental Records Release Form

By completing this form, I hereby request and authorize Garfinkle Family Dental to obtain copies of any and all clinical treatment records and information concerning my care from the below business. These records may include, but are not limited to examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports. Email where the records are to be sent: garfinkledds@gmail.com.

Patient Information

Full Name

First Name Last Name

Date of Birth

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Month
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Day Year

Office Where the Records Are Located

Name of the Office/Business

Office/Business Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Office/Business Phone Number

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Area Code Phone Number

Office/Business Email
*

By signing below, you authorize Garfinkle Family Dental to request your records on your behalf. Please allow up to two business days for your request to be processed and handled. If you have any additional questions or concerns, please don't hesitate to contact us.